End of Life Care Training

towards the end of life

people

bodies respond differently

and is not to say that

all of these symptoms are

present or any of these symptoms.

However, they are common

and are often seen very often

impact

on

the physical support that is required.

So

people's ability to maintain their activities of daily living if

for this point they were managing them may actually change because of the sudden,

you know, they're they're more fatigue. They're all short of breath.

They're not eating the same.

It is ideal for us to try and optimise and maintain their ability

to do things for themselves for a small way we can

on a lot of that is going to depend

on us being able to significantly manage these symptoms

so regardless of the life limiting illness

that somebody

is suffering with, so we talk about a life limiting illness,

use that when there is expected

to be a death,

a direct consequence of a specific illness,

so that's any kind of degenerative disease

or any kind of significant deterioration just related to ageing,

say some really good examples are cancer. That's the life liberty illness.

But so his heart disease

second COPD

dementia is a life limiting illness,

heart failure,

any kind of neurodegenerative diseases. The park concerns

chronic liver disease, chronic renal disease,

a word count as a life. Liberty get all this.

But regardless of whatever one of those

suffering from it doesn't matter about the diagnosis,

they're going to probably experience some comments symptoms,

which is just related.

Tiu. The bodies were shutting down rather than to disease itself.

And you see, there was, you know, fatigue, loss of appetite, pain,

shortness of breath.

At some stage in their disease trajectory,

they're probably going to come across some of these problems

that the severity of this in terms do you tend to very, quite greatly.

Other symptoms, such as delirium, constipation, norther, vomiting

very much depend actually on the diagnosis.

So often palliative care residents will experience

more than one symptom,

and often they have quite a few of them together. We call that a symptom cluster,

so example of a common symptom class that you're going to see its fatigue,

loss of appetite,

pay.

And, as I said, there is going to need to be a

a management plan of how we're going to control their

symptoms that they could be as comfortable as possible,

but also to try to get them to carry on doing things as much as they can.

As much as possible

towards the end of life,

it may be looking at nor medicine. They may have been on whether it's still

developing,

whether they need to stay on certain medications or whether they be stopped.

There may be some medications that they were on before that they need to be continued

or even

replaced with perhaps a different type of medicine.

It may be that we need to consider if aural medicines need to be

described differently. So, for example,

tablets become liquid liquid,

become injections and so on.

And then it's also considering about those anticipatory drugs.

So what might they need in the future? How might be symptoms present

again, going back to those kind of common clusters of some terms,

We can generally predict what might happen,

and we can have all of that medication ready and raring to go.

So there are five common medications used in end of life care.

You talk a little bit about some of them.

I want to mention relax and or sedative medication for agitation.

So the literature does

endorse palliative sedation,

which is then carefully to titrate ID to the needs of the individual

aim.

There is still there. There's guidance in place.

The European, a social association

Palliative care, has issued guidance around sedation. At the end of mirth.

There is quite a lot of disagreement from doctor to doctor, a specialist,

a specialist about

how that should be implemented.

And it's mostly around the level of subsidization

that should be given or is recommended.

It's previous association

with hastening death

in palliative care means that sedation is very often treated with caution.

So probably a fundamental question that we want to

ask here is Does palliative sedation effect survival?

And actually

there has been

research that has

has addressed this,

and actually it looked at

people that were on different levels of sedation

on looked at people that in the half sedation it all all at the end of the life,

a lot of retrospective studies. So they came together this

review on but actually indicated that the duration

of life is not effective by palliative sedation.

That's really important point.

That's the dating. Someone does not maketh, um, die faster.

It just means they die with our agitation.

And that is an incredibly important ethical

question that may arise,

which does have an evidence based answer.

We'll talk about nutrition and hydration in just a moment,

but it's just the highlight

towards the end of life. We've talked about what we know.

People are moving into this final days that they aren't really going to be drinking

because the body has not prioritised that anymore. It's no need for the body.

The band can still become very dry, and that could be quite uncomfortable.

So keeping that person's mouth healthy,

maybe that we the to freshen it with water with ice with any way that we can.

It may be that they can take little sips here and there.

It might be that we need todo haps. Be

looking inside the mouth for ulcers.

We need to be treating any sort of mouth problems that arise.

Mouth care is really important towards the end of life,

so just a good tip.

I would always use the pen torch to have a good look inside their mouth,

and because of lines you won't miss it just by looking

from it far or

just from in front of those. We get them to open the mouth and have a good look,

and you can actually just dip a straw

in a glass of cold water.

If you just put your finger over the hole with the top of it, stops it from running out.

And then you could give just small drops of fluid by releasing your finger slowly.

Other people have used things like a syringe just dropping

water in Mathura slowly or even on a little spoon,

but obviously just been mined for that, you know, pushing too much fluid,

intimate once where they go

coffin splatter. Be mindful. Swallowing difficulties as well,

which is used to use mouth swabs, are like little sponges on a stick.

Certainly have been some issues with

the safety of those. Please be mindful of that.

Nutrition on hydration, a particularly hydration,

just remained such a controversial

topic. For the end of life has been a lot of media criticism,

particularly around the Liverpool care pathway that people were

stop from eating drinking.

There is again an evidence base regarding when Tiu

when not to hydrate at the end of life.

But it's very compelling. It's a very strong evidence base

and it rains a good guidance of good practise for a while.

So there is quite a blanket policy, really, of artificial hydration.

Well, no artificial hydration is pretty

ethnic F ic it ray.

Indefensible. Really.

Towards the end of life, people

need for food and drink it lessons

on

a lot of the time we've got to consider

first or a dry mouth

could be called the medication.

So we've mentioned that good mouth care is that essential

and good palliative care does include the option

of

artificial hydration. If there is a correctable cause,

so that assessment needs to be looked at

on a daily basis, you know the risks

that is benefit

in going by this quo. We need to make sure that we are

educating on day keeping our

relatives informed and

make sure that they understand because we shouldn't really be doing stuff

in the interest of kind of

the wishes of distressed relatives. The distress she's not eating, not drinking.

So

is that of understanding

Why then, oh, eating and drinking

and we're going ahead and giving artificial hydration to appease them,

and we shouldn't be doing it. For that reason

I've been,

there is no a lot of evidence that made people the

majority of trials who are at the very end of life,

so

survival days or weeks that people who literally going to live days or weeks

are going to get no significant benefit. With hydration interventions.

However, there is suffering dehydration

the same way that

any world could suffer. Dehydration can potentially be reversible for some,

but I think the main word here that we need to focus on is potentially

so.

A lot of our recent research examining

hydration actually reveals there's no real clinical benefit

and symptoms on survival.

And

perhaps the only benefit we tend to see

is a possible reversal of delirium

because that delivery on may be

a symptom of the dehydration.

The same applies to

nutrition

again. Do always consider your reversible

causes. And

as someone moves into the palliative stage,

they may at this point the eating less rather than

being in the final stages

of dying, actively dying with it. No eating it all

on that build up

to that time,

they may just be having a loss of appetite.

There may be eating less for various reasons

on it may be

that at this point,

doing things a must. For example, it's not appropriate.

Any diet restrictions are in place. Fluid restrictions.

You're diabetic restrictions or maybe

holding on them.

Maybe we're needing reviewing. Do they? Are they really necessary at this point

and think about how

lack of nutrition or lack of hydration may be impacting on symptoms,

and it may be that we can offer little, and often if they've got that ability

to swallow,

they may be put off by certain fuse.

Who might need to consider changing their diets of things they used to enjoy,

used to like eating May not,

you know, be suitable for them.

It might be that we can get them to drink cups of tea, but we could get them Tiu meal.

That's fine. That is what we go with

again. It's about explaining to that family

resident themselves that the decreased appetite

is part of that natural process of dying,

and

and that might help to diminish those pressures and to get them to eat.

And those anxieties what happens if they don't eat

once you've considered in treating

any symptoms that may have impact. Something's that pain, dry mouth, nausea.

That's why they're no eating

and

who have a look at,

perhaps

discuss what fees may bring some enjoyment than

and that might be something that they're keen or happy to try

goals. At this point, I'm not going to be about reversing nutritional deficit,

but only about managing symptoms and improving the quality of life

again if they are

have moving

towards the dying phase.

Losing that ability to swallow

good aural hygiene is what remains paramount so that math care

in some occasions specialist inputs such a hospice is palliative care teams

may be appropriate.

End of Life Care Training

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